CAJ | 학술논문

目的：对老年抑郁症坠床不良事件调查，找出坠床主要原因及次要的原因，反馈给科室，促使临床医疗护理人员重视医疗安全，采取措施减少坠床不良事件的发生。方法对2000年至2013年老年抑郁症病人发生坠床不良事件30例回顾性调查，由医务科牵头、护理部、质控办、科室主任、主管医生、护士长、专业护士组成召开分析讨论会，通过质量控制工具的分析主要原因和次要原因，反馈给科室整改，对几年内发生率进行比较。结果遵循“PDCA”循环原理，采用管理工具“FOCUS-PDCA”法对相关案例进行持续整改，坠床事件明显减少，效果明显。
목적：대노년억욱증추상불량사건조사，조출추상주요원인급차요적원인，반궤급과실，촉사림상의료호리인원중시의료안전，채취조시감소추상불량사건적발생。방법대2000년지2013년노년억욱증병인발생추상불량사건30례회고성조사，유의무과견두、호리부、질공판、과실주임、주관의생、호사장、전업호사조성소개분석토론회，통과질량공제공구적분석주요원인화차요원인，반궤급과실정개，대궤년내발생솔진행비교。결과준순“PDCA”순배원리，채용관리공구“FOCUS-PDCA”법대상관안례진행지속정개，추상사건명현감소，효과명현。
Objective falling bed incident investigation ,find out the of senile depression ,falling out of bed main reason and secondary cau-ses ,feedback to the Department of nursing staff ,promote clinical medical attention to medical security ,take measures to reduce the occurrence of adverse events from falling off the bed .Method in 2000-2013 years of senile depression patients falling out of bed adverse events were investigated in 30 cases of review ,medical department ,nursing department ,led by quality control office ,department director ,director of doctor ,nurse ,pro-fessional nurses held a discussion will ,through the analysis of the main reasons of the quality control tools and secondary causes ,feedback to de-partments for rectification ,to compare the incidence rate of several years .Results follow the"PDCA"cycle principle ,continuous rectification of cases related to the management tool "FOCUS-PDCA"method ,falling out of bed events obviously decreased ,obvious effect .